session2 june18-june22 - the YMCA of Delaware

PAYING FOR CAMP ON THE BANK DRAFT/EFT SYSTEM
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Camp fees must be paid in full prior to the start of your child’s camp session.
To begin bank draft, complete section 1 and return with a blank voided check and your registration form
to the Y. If you would like to utilize the credit card EFT option, complete section 2 and return with your registration
form. Please fill in credit card number. We need your signed authorization to charge correct account.
Zip Code is necessary for processing. ______________________________________________
Please check start date: ____March ____ April ____May ____June ____July
1. Bank Draft Option (need voided blank check)
Name of Parent _______________________________________________________________________________________________________________________________
Name of Child ________________________________________________________________________________________________________________________________
Draft on 1st of month _____ Draft on 15th _____ Draft on both dates_____
Please check start date: ___March ___ April ___May ___June ___July ___August
2. Credit Card EFT (must fill in credit card #. Please do not write number on file)
Card Type: (AMEX, VISA MC, DISCOVER)_______________________________________________________________________________________
Card Issuer (bank or credit union):________________________________________________________________________________________________
Account Number: _______________________________________________________________________ Expiration Date: MM/YY __________ / __________
Name on Credit Card:_________________________________________________________________________________________________________________
Current Billing Address:_______________________________________________________________________________________________________________
City, State ___________________________________________________________________________________ Zip Code: _____________________________
Phone Number: _______________________________________________ E-Mail______________________________________________________________
Draft on 1st of month _______ Draft on 15th _______ Draft on both dates_______
Child’s Name (first and last) __________________________________________________________________________________________________________________
Please check start date: ____March ____ April ____May ____June ____July
I hereby authorize the Y of Delaware, to initiate debits to the bank/credit cards listed above and authorize
the bank to debit my account.
Signature__________________________________________________________________________________________________________________________________________________________
Please direct all questions to Gina Kapa, at the Brandywine Y, 478-9622, ext. 61.
BRANDYWINE YMCA • Summer Day Camp 2012 • (302) 478-YMCA • www.ymcade.org